Transcription of COMMISSION AUTHORIZATION FORM - Foremost Insurance
1 COMMISSION AUTHORIZATION FORMForm 735281 11/15 ConfidentialINSTRUCTIONS: Please have the Agency Principal or Authorized Officer complete the information below to authorize or remove access to Specialty Products and/or Business Insurance online COMMISSION statements. For each individual included in the COMMISSION access request that is not already set up in our processing systems, please complete and return the appropriate form : Producer Information form (for each producer requiring appointment) Non-Licensed Staff form (for each staff member requiring online access)AGENCY PRINCIPAL INFORMATION:Name (Print Name)Name (Signature):Producer Code:Title: Date:Agency Address :City:State:Zip Code:Office Phone Number:( )AUTHORIZEd STAFF CHANGE INFORMATION (Check all that apply):Authority Access: o Authorize Access o Remove Access o Specialty o Business Insurance Authority Access.
2 O Authorize Access o Remove Access o Specialty o Business Insurance Date: For: (Print Name) (Title)Date: For: (Print Name) (Title)Please have the Agency Principal or Authorized Officer complete this formPlease email or fax this completed form to Agency Contract ManagementE-Mail: FAX: 616-956-4369
